click to enlargeA report of progress in smartphone ownership by those over 65 years of age is mixed indeed. There’s progress–ownership is up to 42 percent of the age group, and 64 percent of these smartphone owners are users of the Internet according to Pew Research‘s 2016 study. But mitigating factors to this good news is that ownership is very much a function of income and age. According to the US Census’ American Community Survey 2015, 66 percent of those aged 65+ households with income $70,000+ own smartphones, but that declines to 33 percent in the 75+ age range and 27 percent of those 80+. Perhaps Laurie Orlov exaggerates the cost of smartphones, especially Android–this Editor has never bought an LG phone over $200 and has a miserly data plan, using Wi-Fi most of the time; Verizon has plenty of new older models at lighter prices and other carriers like Consumer Cellular and GreatCall have excellent deals. But what is true is that interest wanes with age–and that phones, especially Apple, still present legibility and usability barriers to those with low vision or hand arthritis. Ms Orlov also notes Pew’s discovery that 65+ users are less likely to secure their phones with lock codes and regularly update their apps. Aging in Place Technology Watch

click to enlargeGuest editor Sarianne Gruber (@subtleimpact) scopes the ‘digital divide’ separating those who need health services the most from the patient engagement and other tools they need in this article. The studies are US, but the lessons apply anywhere in the world. This Editor notes that many patient engagement tools are over-designed and over-complicated for users, even if they are fairly competent and frequently use online and mobile. (I entered a ‘pilot’ of a stress reduction program which proved to be anything but–and quitting because it is invasive and the reporting is ludicrously burdensome.)

To developers: Imagine your patient engagement platform being used by a person on the less sophisticated, less educated and disconnected end of the spectrum–or by someone less able due to physical (vision, touch) or cognitive impairment. Put on bad glasses and gloves–and start. Better yet, find a few people and put it in front of them. If we can make the mental shift in developing mobile apps for Africa or India, certainly we can do so for Americans, Britons and Europeans.

What the Studies are Showing

Hallmarked as a solution to improve healthcare quality, cost and safety, studies are showing health technology is up against a “digital divide” when it comes to patient engagement. At the Internet Governance Forum, Pew Research Center’s Lee Rainie, Director of Internet, Science and Technology Research presented the Fact Tank Report discussing the “digital divide” that exists in 2016. The report documents that lower income, less educated, non-white, seniors and rural communities are the least likely to have home internet, home broadband, mobile connectors and smartphones. This summer’s medical publications, the Journal of the American Medical Association and the Journal of the American Board of Family Medicine, released studies where demographic and socioeconomic data marked the root causes to limited or no access to digital technology, thus hindering the benefits and improved outcomes it can bring to the neediest and most costly populations. Here are the highlights from each study.

Trends in Seniors’ Use of Digital Health Technology in the United States, 2011-2014, a research letter submitted from Harvard Medical School’s Brigham and Women’s Hospital, appeared in the August 2, 2016, JAMA. Authors, David M. Levine, MD, MA, Stuart Lipsitz, ScD, and Jeffrey A. Linder, MD, MPH,FACP made mention that this study, based on the National Health and Aging Trends survey (NHATS), was exempted from the Partners HealthCare Human Research/IRB Committee. The research team included participates to the longitudinal NHATS survey in 2011. The participants were re-surveyed annually on everyday (nonhealth) and digital health use until 2014. The research team acknowledged that this may be the first nationally representative study to examine trends in the adoption of digital health technology by seniors age 65 years and older who are community-dwelling Medicare beneficiaries.

As we approach what we in these less-than-United States think of as the quarter-mile of the summer (our Independence Day holiday), and while vacations and picnics are top of mind, there’s a lot of news from all over which this Editor will touch on, gently (well, maybe not so gently). Grab that hot dog and soda, and read on….

Split decision probable for US insurer mergers. The Aetna-Humana and Anthem-Cigna mergers will reduce the Big 5 to the Big 3, leading to much controversy on both the Federal and state levels. While state department of insurance opposition cannot scupper the deals, smaller states such as Missouri and the recent split decision from California on Aetna-Humana (the insurance commissioner said no, the managed care department said OK) plus the no on the smaller Anthem-Cigna merger are influential. There’s an already reluctant Department of Justice anti-trust division and a US Senate antitrust subcommittee heavily influenced by a liberal think tank’s (Center for American Progress) report back in March. Divestment may not solve all their problems. Doctors don’t like it. Anthem-Cigna have also had public disagreements concerning their merged future management and governance, but the betting line indicates they will be the sacrificial lamb anyway. Healthcare Dive today, Healthcare Dive, CT Mirror, WSJ (may be paywalled) Editor’s prediction: an even tougher reimbursement road for most of RPM and other health tech as four companies will be in Musical Chairs-ville for years.

‘thedarkoverlord’ allegedly holding 9.3 million insurance records for cyber-ransom. 750 bitcoins, or about $485,000 is the reputed price in the DeepDotWeb report. Allegedly the names, DOBs and SSNs were lifted from a major insurance company in plain text. This appears to be in addition to 655,000 patient records from healthcare organizations in Georgia and the Midwest for sale for 151 – 607 bitcoins or $100,000 – $395,000. The hacker promises ‘we’re just getting started’ and recommends that these organizations ‘take the offer’. Leave the gun, take the cannoli.HealthcareITNews It makes the 4,300 record breach at Massachusetts General via the typical unauthorized access at a third party, once something noteworthy, look like small potatoes in comparison. HealthcareITNews Further reading on hardening systems by focusing on removing admin rights, whitelisting and endpoint security. HealthcareDataManagement

Should VistA stay or go? It looks like this granddaddy of all EHRs used by the US Veterans Health Administration will be sunsetted around 2018, but even their undersecretary for health and their CIO seem to be ambivalent in last week’s Congressional hearings. According to POLITICO’s Morning eHealth newsletter, “The agency will be sticking with its homegrown software through 2018, at which point the VA will start creating a cloud-based platform that may include VistA elements at its core, an agency spokesman explained.” Supposedly even VA insiders are puzzled as to what that means, and some key Senators are losing patience. VistA covers 365 data centers, 130 separate VistA systems, and 834 custom installations, and is also the core of many foreign government systems and the private Medsphere OpenVista. 6/23 and 6/24

click to enlargeThe King’s Fund is still bullish on the transformative capabilities of technology-enabled care services for health (even if others are not, see following article). This article (which almost passed this Editor by this month) highlights eight areas which have the greatest potential. Some are expected–but at least two are surprises. You be the judge!

Smartphones: apps, as hubs/hub replacements, and research transmitters (voluntary but also involuntary?)

Blockchain, the tech behind bitcoin; decentralised databases, secured using encryption, that keep an authoritative record of how data is created and changed over time, to bring together decentralized health records. (Surprise #2)

The connected community; P2P support networks and research communities

Researchers at MIT are working on a project to measure the heart rate and breathing using a smartphone’s accelerometer in the user’s pocket or bag without the need for wearable sensors. When the user is at rest the slight movements due to breathing and heart beat are measured using the smartphone and used to derive the heart and breathing rates.

According to a paper published recently, in a test with a dozen participants (a very small sample for this type of test) the heart rates measured using the new method were within one beat when compared to FDA approved sensors they were using simultaneously. The measurements of breathing rate were about a quarter of a breath of the approved sensors.

The aim is to sense when someone is stressed by using the heart rate and breathing and then help cope with the situtation by suggesting, say, breathing exercises or calling for help.

The answer, according to health tech industry analyst Laurie Orlov (Aging in Place Tech Watch, Boomer Health Tech Watch) is…not really. Despite its massive size (76 million in the US), spending power (by 2017, 70 percent of US disposable income), breadth (1946-64) and need (despite living longer, by 2030 37 million will be managing more than one chronic condition), most health apps, especially fitness apps, don’t resonate with boomers despite over 50 percent having smartphones. The reasons are many–they’re complicated, often hard to follow, view, and abandonment across all ages is still high. Even among Fitbit purchasers, abandonment is fully one-half. As income decreases, smartphone access also becomes a cuttable budget item. Much more in this paper published by the California Healthcare Foundation.

The programs would use mobile, online and texting, which doesn’t require a smartphone and has historically worked well in compliance and information (e.g. Text4Baby). For the critics, however, Pew Research found that half of those with incomes under $30,000 have smartphones. This number also includes the elderly, and does not take into account recent growth–smartphone prices have decreased smartly, and are now available on pay-go plans. iHealthBeat

click to enlargeThe Gimlet Eyehas that certain half-baked radioactive ‘glow’. The healtherati are all aTwitter over a New York Times Style (!) section article that does the unthinkable–it dares to raise the question of the possible harm of radiation that wearables, including smartwatches as well as smartphones, might present to both adults and children. The writer, Nick Bilton, is a regular tech columnist.

After an unfortunate baiting for attention at the start, making an analogy of cellphone/wearable radiation to 1930s adverts with doctors ‘endorsing’ cigarettes, he for the most part tries to take a balanced approach. By the end, he lines it up like this. Bluetooth LE and Wi-Fi–no evidence of harm in adults. 3G/4G cellphone radiation–you may want to be careful. He points out that studies aren’t definitive. Older studies, such as the WHO’s, a Swedish and some European studies point to harmful (carcinogenic) effects from phones held extensively too close to the head, but nothing is definitive in causality as the CDC pointed out and additional studies have proven no conclusive evidence of harm. Conclusion–use anything 3G/4G with caution, away from the head, limit exposure by children or pregnant women. Cautious enough?

Oddly, he advocates Bluetooth headsets but doesn’t mention using speakerphone settings–and then, for the smashing windup, won’t put the Bluetoothed Apple Watch near his head. It’s a weirdly sourced (an alternative doctor the only one cited? Old studies?) and half-baked, partially tossed salad article. Consider: most wearables are–surprise, Bluetooth or Wi-Fi connected. But it does bring up the inconvenient question, only partially answered, of All Those Rads and What (If Anything) Are They Doing To Us.

What’s really interesting? The immediate, twitchy and prolonged press response. As they say in New Jersey, they are ‘jumping ugly’. (more…)

click to enlargeAccording to multiple press sources in the past 24 hours, the anxiously-awaited Apple Watch is rumored to be having big trouble with its more advanced healthcare measuring features. We noted at the time “Haptic engine and heart rate monitor; 4 lenses. infrared, LED, photo sensors detect pulse.” plus daily activity [TTA 9 Sep, 11 Sep 14]. Well, not quite. The Wall Street Journal broke the news that it will not debut in April including monitoring of “blood pressure, heart activity and stress levels” as originally planned because, simply, the watch did not measure them reliably and accurately (hairy, sweaty arms!), they were too complex or required regulatory approval (not so–see FDA and MDDS).

Apple has relied on the Watch to defend its Still Most Innovative Company Post-Jobs turf, (more…)

NHS England has sketched out the future of healthcare and it will be one using smartphones and wearable bio-sensors to monitor ourselves and alert clinicians. click to enlargeNHS National Medical Director Sir Bruce Keogh has written to around 250 organisations across health, social care, industry and third sector asking them to support the Technology Enabled Care Services (TECS) programme which he says will take the NHS into this new technological era.

The TECS programme, born out of the Three Million Lives (3ML) initiative (which didn’t quite go anywhere after all the song and dance, including from Prime Minister David Cameron), was reviewed last year resulting in the change of focus to “address the demand for support and practical tools to commission, procure, implement and evaluate technology enabled care services” according to Sir Bruce’s letter as reported on the NHS England website.

The TECS Stakeholder Forum‘s views and proposals now form the TECS Improvement Plan for 2014-17. This is a broader group following the failure of the 3ML Stakeholder Forum, which consisted mainly big industry organisations, to achieve anything of substance.

According to the NHS England website posting, Sir Bruce explains: “To ensure continued progress, we have brought together a TECS Implementation Group consisting of experts and leaders from across these sectors whose remit is to support the strategic development and delivery of the proposals within the Improvement Plan. In addition, we have formed the TECS Executive Steering Group which meets regularly to provide clinical, technological and strategic leadership for the programme at a director level in NHS England.”

This all sounds like a lot of bureaucracy and a drawn out attempt to rescue what remains of the 3ML programme. I started thinking of the Titanic and deck chairs.

For those of us suffering from insomnia there’s no denying it can be a real pain! For some it means wakening up a number of times throughout the night, while others are unable to get back to sleep after only a few hours rest. In my case it means drifting off into a peaceful slumber before inevitably waking just minutes later with a jolt, looking like Frankenstein’s monster and wondering if someone just hit me up the face with a bolt of lightning!

Surprisingly in the tech-addicted (and young-skewing, based on subject matter) Gigaom is this short piece on how health tech companies are missing the boat by targeting the young, healthy fitness addict or plain addicted-to-the-data Quantified Self (QS) market, rather than those over 50 and their families. ‘Simple’ and unobtrusive are the keywords, especially for what the late and much missed MetLife Mature Market Institute termed the ‘old-old’–those over 80. Mentioned are home activity monitoring systems such as Lively, BeClose and GrandCare Systems supplanting the PERS pendant (Lifeline) and the additional alert capabilities offered by GreatCall/Jitterbug. (This Editor will also mention a new telecare system entering the European and Americas markets, Essence Care@Home, which premiered at Mobile World Congress 2014. More on this in the next few days.) What’s notable about the article is the emphasis on the market size (via expert Laurie Orlov): $2 billion now, ten times that in 2020. What’s incomplete about the article is no ‘look-ahead’ to how devices like smartwatches (and watch-like forms such as AFrame), sensor-based wearables which connect to smartphones–and sensor-equipped smartphones, tablets and even Glass-type devices with simple apps which can help with self-or group-monitoring, prompts for those with cognitive difficulties, and more. Worldwide, we are also running out of carers [TTA 24 April]. Who will crack the code on tech for seniors?

Apple have filed a patent for a “Mobile emergency attack and failsafe detection” which uses the iPhone’s inbuilt sensors to detect a probable emergency situation, such as a physical attack against the user. When the device is in ‘attack detection mode’, certain events can cause it to request help automatically, by calling a defined emergency contact or the emergency services. The GPS co-ordinates can also be transmitted. Apple Insider

The Scottish Health Secretary, Alex Neil, has announced the investment of an additional £10 million click to enlarge(about US $ 15 million) to support home health monitoring solutions across Scotland, the BBC has reported. This additional funding for the NHS Boards will enable people to use technology such as tablet computers and smartphones to monitor conditions such as diabetes, heart problems and lung problems at home, the report added.

In 2011, Nicola Sturgeon MSP, Cabinet Secretary for Health, Wellbeing and Cities Strategy in Scotland set out her strategic vision for achieving sustainable quality in the delivery of healthcare services across Scotland, in the face of the significant challenges of Scotland’s public health record, changing demography and the economic environment. The Scottish Government’s 2020 Vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting and, that Scotland will have a healthcare system where, amongst other goals, there will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

Mr Neil’s announcement was made during a debate in the Scottish Parliament entitled ‘Update on Delivering the 2020 Vision in NHS Scotland’. Mr Neil claims past efforts in telecare and telemedicine have meant that £2.8 million has been “ploughed back” into Scottish frontline services and reduced emergency admissions to hospital by 70 per cent.

Health apps are often in the news these days. Ofcom, the UK telecommunications regulator, commissioned Kantar Media to carry out qualitative research on attitudes and behaviours of apps users when using devices such as smart phones and tablets. The resulting report, Apps Environment, published today by Ofcom makes interesting reading.

Although the report was commissioned by the UK regulator, I think the findings are applicable to any country. What’s more, the generic nature of the conclusions make them relevant to health apps as much as to any others.

The report says that “among app users, several perceptions were found to be influencing behaviours, attitudes and the low level of concern in the app environment. These perceptions were:
• official app stores monitor and vet the apps they make available;
• well-known brands provide a safe, secure and reliable user experience, and;
• apps are safer than browsers due to their more limited and contained nature compared to browser-based internet use.”

Another finding was that many app users said they paid very little attention to permissions requested by apps – nothing new there then. How many times have you ticked that “I Agree” box to the terms and conditions without reading them?

Very few participants in the research are reported to have raised spontaneous concerns about apps. The researchers say that when prompted, in-app purchasing and advertising were of greatest concern to parents, and at most, a frustration or annoyance to others.

This shows that when it comes to more critical apps such as health apps or those that are designed to provide a safety net in a care environment a stronger regulation may be needed as well as a pro-active educational effort to emphasise the need to be aware of issues such as data privacy.

Another possible weapon against the Continuing Battle of Stalingrad faced by diabetics is in test in the Boston area. A system developed by associate professor of biomedical engineering at Boston University Dr. Edward Damiano (whose son has Type 1 diabetes), and assistant professor at Harvard Medical School Dr. Steven Russell has a sensor inserted under the skin that relays hormone level data to a monitoring device which sends data to an app on the user’s smartphone every five minutes. The app calculates required dosages of insulin or glucagon to maintain optimal blood sugar levels, and communicates the information to two corresponding hormone infusion pumps worn by the patient. Their target for FDA approval and rollout is 2017. Gizmag. Previously Editor Charles and this Editor have written about Diabetes Assistant and two other systems in clinical trials, which also are bringing this to a closer reality [TTA 20 Aug, 5 Aug]

Our definitions

Telehealth and Telecare Aware posts pointers to a broad range of news items. Authors of those items often use terms 'telecare' and telehealth' in inventive and idiosyncratic ways. Telecare Aware's editors can generally live with that variation. However, when we use these terms we usually mean:

• Telecare: from simple personal alarms (AKA pendant/panic/medical/social alarms, PERS, and so on) through to smart homes that focus on alerts for risk including, for example: falls; smoke; changes in daily activity patterns and 'wandering'. Telecare may also be used to confirm that someone is safe and to prompt them to take medication. The alert generates an appropriate response to the situation allowing someone to live more independently and confidently in their own home for longer.

• Telehealth: as in remote vital signs monitoring. Vital signs of patients with long term conditions are measured daily by devices at home and the data sent to a monitoring centre for response by a nurse or doctor if they fall outside predetermined norms. Telehealth has been shown to replace routine trips for check-ups; to speed interventions when health deteriorates, and to reduce stress by educating patients about their condition.

Telecare Aware's editors concentrate on what we perceive to be significant events and technological and other developments in telecare and telehealth. We make no apology for being independent and opinionated or for trying to be interesting rather than comprehensive.